The Top 5 Reasons Workers’ Compensation Claims Are Denied and the Appeal Process

When an employee is injured on the job or becomes ill as a result of their job duties, workers’ compensation provides a safety net to cover medical expenses and provide income until an individual can return to their normal tasks. However, even when individuals have been injured on the job, it is not uncommon for their workers’ compensation claims to be denied. Being aware of the various potential reasons for denial and knowing how to appeal will make a significant difference in your ability to obtain the benefits you deserve. Our Raleigh workers’ comp lawyer has prepared a brief guide on the five most common reasons for workers’ compensation claim denials in North Carolina.

Why Workers’ Compensation Claims Are Denied

Five basic reasons for workers’ compensation claim denials include delays in reporting the injury, insufficient medical evidence that the injury took place while performing work duties, failure to prove whether or not the injury was work-related, confusion over whether the injury is new or a pre-existing condition and missed filing deadlines. Let’s break each one down.

Failure to Promptly Report the Injury 

Under North Carolina law, a workplace injury must be reported to the employer as soon as possible but no later than 30 days from the time it occurred. If you wait too long, you risk the insurance company being skeptical about your claim and its validity. You may have a good memory, but it’s often much easier to immediately go to your employer and tell them what happened that led to the injury. Our Raleigh workers’ comp lawyer suggests that the injured worker take a few minutes to write down exactly what happened before reporting the injury. Why? Because your emotions can make it more likely that when you report your injury, you’ll omit some details – or your employer might misunderstand something you have said.  

Lack of (or Insufficient) Medical Evidence

It is important to remember that workers’ compensation claims are based on medical records. Without documentation by doctors that an injury indeed occurred and corresponds to the work incident, you may not get the benefits you deserve. But at the same time, make sure that your medical records say the same thing about the injury and work incident. Inconsistencies can jeopardize the credibility of the claim and lead to denial.

Is the Injury Really Work-Related?

Our Raleigh workers’ comp lawyer frequently sees claim denials resulting from whether the injury was related to employment. The insurer will deny the claim by stating that the claimant’s injury did not occur in the course and scope of employment or that the injury was not related to the job or employment. Therefore, injured parties should obtain statements from witnesses and other evidence to establish the claim that the injury occurred at the job.

Pre-Existing Conditions

If a worker has a pre-existing condition that is exacerbated by a workplace injury, these factors can make the claim more challenging. For example, insurers might attempt to claim that symptoms the employee attributes to their workplace injury are actually the result of their pre-existing condition. Therefore, in these situations, specific medical evidence demonstrating that the workplace injury exacerbated the pre-existing condition is crucial.

Missed Deadlines

North Carolina has very specific deadlines regarding the filing of workers’ compensation claims with very few (if any) exceptions. Missing those deadlines nearly always results in an automatic denial of the claim. Therefore, it is very important to always be aware of (and meet) all filing deadlines to prevent unnecessary denials of your workers’ compensation claims. A skilled Raleigh workers’ comp lawyer will be able to assist you with that. 

How to Appeal a Workers’ Compensation Claim Denial in North Carolina

Even if your workers’ compensation claim is denied, you still have rights, namely, the right to appeal. The following is a six-step plan to assist you in filing an appeal in North Carolina: 

1. Within 30 days after you receive written notice telling you that your claim was denied, you should file your appeal to the North Carolina Industrial Commission. 
2. The next step – within 14 days – is to have a formal conference with the party (attorney or self-represented) that filed the denial. 
3. The third step, within 10 days, involves your submission of a report that summarizes the evidence in your case. It can include witness statements and reports from treating or consulting doctors. 
4. Your fourth step, within 28 days, is to exchange discovery with all parties, including subpoenas for medical record information. 
5. The fifth step of the appeal involves a mediation conference done by a mediator provided by the North Carolina Industrial Commission who will facilitate the meeting and discussion between the parties and an attorney. You have one month from receiving the order of hearing to schedule the mediation. 
6. The sixth and final step is the hearing with a hearing officer appointed by the Industrial Commission. 

Understanding the Reason for the Denial

Carefully read the letter from the insurer, which should set forth the exact rationale for the denial. Understanding why your case was denied is an important first step toward filing a good appeal for benefits. Do you have questions, or are you unsure about what the letter from the insurer says? Give a Raleigh workers’ comp lawyer.

Tips for a Successful Appeal

Tip #1: Maintain meticulous records of all communications, doctors’ visits, and any documentation related to your injury and claim.

Tip #2: Make sure that all the reports and statements match up with respect to the injury. An inconsistency can (and most likely will) weaken your case.

Tip #3: Consider seeking legal guidance early in the process. An experienced workers’ comp attorney can significantly increase your chances of a successful appeal.

Speak to a Knowledgeable Raleigh Workers’ Comp Lawyer Right Away

Concerns over a denied workers’ compensation claim can be troubling at first, but gaining awareness and having an understanding of the most common reasons as to why you were not initially successful with your claim can make a huge difference in the ultimate outcome. If you have a claim in Raleigh or elsewhere in North Carolina, a Raleigh workers’ comp lawyer in our office is ready to help. Contact us today.